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NEW PATIENT APPLICATION & INTAKE FORM
1464 E. Whitestone Blvd, Ste. 1403, Cedar park, TX 78613 Phone: 512-456-7508 Text: 512-553-3573
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Date
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Name
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Occupation
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Height, Current weight, Ideal weight, Weight one year ago.
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Partner's age & health condition. If you don't have life partner please put N.
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Parents age & health condition.
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Children DOB & health condition. If you don't have any children please put N.
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Siblings age & health condition. If you don't have any sibilings please put N.
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Family/ Living situation
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Stressful life events
Studies show that past and continued trauma play a significant role in health and health outcomes. Our understanding of your history will help us to best support you moving forward.
Have you lived or traveled outside of the US? If so, when & where?
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Have you and/or your family experienced any major life changes before or around the time these health concerns were evolving? If yes please explain briefly.
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Have you experienced one or more of these stressful life events or traumas in your life? Please check mark the ones you've experienced.
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Death of a family member, romantic partner or very close friend because of accident, homicide, or suicide or even natural death.
Mental, Sexual or physical abuse by a family member, romantic partner, stranger, or someone else.
Emotional neglect or abuse such as ridicule, bullying, put downs, being ignored abandoned or told you were no good by a familymember or romantic partner.
Discrimination.
Life-threatening accident or situation (military combat or lived in a war zone).
Life-threatening illness.
Physical force or weapon threatened or used against you in a robbery or mugging.
Witness the murder, serious injury or assault of another person.
Other:
Required
Emotional condition: Most of the time I feel
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Happy
Grateful
Content
Bliss
Sad
Angry
Enviess
Hopeless
Worthless
Guilty
Fear
Other:
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How do you handle stress? (0 horrible to 10 Great)
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